How to manage Erectile Dysfunction

Erectile dysfunction is the inability to achieve or maintain an erection that is sufficient for satisfactory sexual intercourse. 

Types of Erectile dysfunction

Erectile dysfunction can be of the following types based on the mechanism of dysfunction

• Organic 
• Psychogenic

Causes of Erectile dysfunction

Erection is caused and maintained by physical as well as central and peripheral neurological factors and the degree of contraction of the cavernously smooth muscle is responsible for the state of erection. Erection occurs in response to touch, smell, and visual stimulation. The muscles in the penis, the blood supply, the peripheral nerves as well as the autonomous nervous system have to function properly together to achieve and maintain a proper erection. 
The following may cause or contribute to erectile dysfunction

• Vascular causes - 
  • Atherosclerosis
  • Peripheral vascular disease
  • Myocardial infarction
  • Blood vessel and nerve trauma (eg, from long-distance bicycle riding)
  • Medications for treatment of vascular disease
• Systemic diseases - 
  • Diabetes mellitus
  • Hypertension
  • Renal failure
  • Liver cirrhosis
• Neurological causes - 
  • Epilepsy
  • Stroke
  • Multiple sclerosis
  • Guillain-Barré syndrome
  • Alzheimer disease
• Respiratory disease-
  • Chronic Obstructive Pulmonary Disease
  • Sleep Apnea
• Endocrine Disorders -
  • Hyperthyroidism
  • Hypothyroidism
  • Hypogonadism
  • Diabetes
• Conditions affecting the penis - 
  • Priaprism
  • Epispadias
  • Peyronie Disease
• Blood Disorders - 
  • Sickle cell anemia
  • Leukemia
• Surgical Procedures -
  • Brain and spinal cord surgeries
  • Surgeries in the pelvic region
  • Transurethral resection of the prostate
  • Radical prostatectomy
  • Cystectomy
• Medications - 
  • Antihypertensives 
  • Antipsychotics
  • Antidepressants
  • Antiulcer agents - such as cimetidine
  • Cholesterol lowering agents
  • Methadone
  • 5 Alpha reductase inhibitors - such as finesteride, dutasteride
• Lifestyle -
  • Smoking
  • Alcohol Consumption
  • Substance and recreational drug use
  • Sedentary lifestyle and obesity
• Psychological Causes - 
  • Depression
  • Anxiety, performance anxiety
  • Stress 
  • Mental health disorders

Symptoms & Signs

Erectile dysfunction may include the following symptoms

• Inability to achieve an erection despite of the presence of sufficient sexual stimulation
• Inability to maintain an erection long enough to complete sexual intercourse in spite of sufficient sexual stimulation

Investigations

The following investigations may be done

• Laboratory tests - 
  • Hormonal studies - 
    • Testosterone - total and free testosterone levels, and specially early morning levels
    • Leutinizing Hormone (LH) levels - to assess if the defect is central or in the testes
    • Prolactin levels - to check for pituitary hyperfunction, as in pituitary tumors
  • Lipid profile
  • Fasting Blood sugar and HbA1c
  • Liver function tests
  • Complete urine Analysis
  • Renal function tests
  • Serum Metabolites
  • Prostate Specific Antigen
• Prostaglandin E1 Injection - to assess the blood flow in the penis; done by injecting prostaglandin E1 directly into the corpora cavernosa muscle on one side
• Biothesiometry - to assess the state and functioning of the nerves through vibrational stimuli
• Dynamic Infusion Corpus Cavernosometry - to assess the vascular pressure inside the corpora cavernosa muscles during an erection; done by pumping fluid at a known rate and pressure into the shaft of the penis
• Nocturnal Penile Tumescence - to evaluate the presence of nocturnal erections during REM sleep. Individuals with erectile dysfunction do not have nocturnal erections
• Ultrasound - Penile Ultrasonography with Doppler, or Duplex ultrasonography - to assess the blood flow in the cavernosal arteries before and after an erection achieved by injecting Prostaglandin E1

Diagnosis

A diagnosis of erectile dysfunction and its cause may be established based on medical history, clinical evaluation, and results of the investigations done. 

Treatment Options

The treatment of erectile dysfunction is aimed at treating both the identified underlying cause as well as erectile dysfunction itself. The treatment of erectile dysfunction will also depend on the duration and the severity of the condition. 

Medical Management

Medical management of erectile dysfunction may include the following

• Phosphodiesterase 5 (PDE5) inhibitors - sildenafil, vardenafil, tadalafil, and avanafil. They may be prescribed alone or in combination with another treatment modality. These drugs are not to be taken without a prescription as they can have serious side effects in individuals with other underlying conditions such as heart disease or hypertension 
• Androgens - Individuals with low levels of testosterone, low libido, and erectile dysfunction may benefit from hormone replacement which may be given in oral, injectable, gel, or transdermal (skin patches) form

Indications for Interventions

Some interventions that may be prescribed for erectile dysfunction may include

• Intracavernosal injection of vasodilators -self-injection of drugs like prostaglandin E1, papaverine, or phentolamine; either alone or in combination with PDE5 Inhibitors
• Intraurethral Prostaglandin E1 pellets - MUSE or Medicated Urethral System for Erections - involves the use of small suppositories of prostaglandin E1 that are placed inside the urethra with the help of a special device; it may be effective in individuals with diabetes, vascular disease, or who have undergone prostate surgery

Surgical intervention for erectile dysfunction may include the following

• Surgical revascularization - only done in healthy young adults, who do not have a generalized vascular disease
• Surgical elimination of vascular outflow (venous leak) 
• Penile Implant Placement - various types of implants such as semirigid, fully inflatable, or self-contained inflatable implants are available that are surgically placed into the shaft of the penis

Role of Diet/Exercise/Lifestyle changes/ Preventive

Some other measures that may be used in the management of erectile dysfunction may include

• Constriction devices - a special device is placed at the base of the penis and it helps to maintain the erection. It is useful in individuals with a venous leak phenomenon that prevents them from maintaining a sustained erection
• Vacuum devices or penis pumps - they work by creating a vacuum and drawing the blood into the penis; they are usually used in combination with a constriction device
• Psychological and Sexual Counseling - sexual and psychological counseling in addition to other treatments is important in the management of erectile dysfunction as a whole, in all individuals whether or not there is a psychological component that contributes to the problem of erectile dysfunction

Some measures that can be taken to prevent erectile dysfunction may include

• Keeping health conditions such as diabetes, hypertension and heart disease under control
• Getting regular health checkups and screening tests
• Cessation of smoking, alcohol, and recreational drug use
• Regular exercise and maintaining an ideal body weight
• Getting proper medical help and counseling for mental health issues such as anxiety, stress, or depression
• Establishing  proper communication with a sexual partner

Complications

The complications of erectile dysfunction may include the following

• Mental stress and depression
• Low self-esteem and embarrassment 
• Relationship problems
• Inability to impregnate a partner

Prognosis

The prognosis for erectile dysfunction is generally very good with proper diagnosis and management. However, erectile dysfunction is also an indicator of cardiovascular health, and most individuals with erectile dysfunction have an increased risk of cardiovascular events and it is also associated with anxiety, depression, and a poor quality of social life.